Advanced Communication

Madhura Bhatwadekar
Psychosocial Support Director
Simpatico Palliative Connect
When is communication required
Diagnosis Increase in Change in
symptoms treatment

End of treatment
End of life

Chronicity/
Treatment
terminal Effects of treatment plan
stage of
illness
Common emotions of patients
• Anger

• Restlessness

• Sadness

• Guilt

• Depression

• Fear

• Acceptance
 Are these phrases familiar …
• ‘’Please do not tell her about her cancer ‘’
• ‘’Can you please tell her that she will be alright ‘’
• ‘’He will get depressed if you tell him he has cancer ‘’
• ‘’My wife hopes that I will be up again. Don’t tell her I am dying”
• ‘’If you tell him he will die early because of shock’’
 Collusion
Types of collusion

• Information is selectively or not disclosed

at all to patients and/or relatives. Doctor
Patient
Family
Done by
• Health professionals
• Family
 Conspiracy of Silence

• Anything being withheld or not shared

among individuals involved
• Used as a safeguard

Simpatico Palliative Connect, Pune

 How do you handle these ?

• With the relative’s consent, establish level of awareness

• Elicit worries and questions regarding illness
• Feedback to the relatives regarding the awareness of the illness
and readiness
• Explain to the relative the importance of reassurance and honesty
• Encourage dialogue between patient and relative
 DENIAL
• ‘’His health has improved since last time we met ‘’
• ‘’He has started eating well’’
• ‘’She is feeling more energetic than before ‘’
• ‘’My will power is strong …I will live ‘’

• It is a coping mechanism
• It may reduce anxiety and promote optimal functioning
• It may also result in excessive delay in seeking and
complying with medical treatment
 Scenario
• Patient is38/Male, married with two children, diagnosed case of
NSCLC, underwent chemotherapy followed by radiotherapy. Now
feeling much better now and convinced that he is cured. He is
following active professional life. He undergoes routine follow-up
CT scan .He visits the oncologist who have reports of scan.

• Primary oncologist of Mr Y. had ordered CT scan of chest for

follow up. Reports revealed recurrence of disease with bone
metastasis. Mr Y is asymptomatic at present and is blissful. He has
to break the bad news where patient is not expecting one!
 Breaking Bad News
Any news that alters the perception of
future is BAD NEWS

• Primary responsibility of doctor to

break it
• Has to be done with care
• Needs and concerns need to be
addressed
• Patient and family need to be
supported well after breaking news
 Do We Tell?

• According to studies , 50 – 90% of patients want the truth

• So the issue is not “do we?”
• Issue is “when and how do we?”
• In reality, patients who are dying, know they are dying
• They want confirmation of their status
• They want a time frame
SPIKES
• S- SETTING UP the Interview
• P- ASSESSING THE PATIENT'S PERCEPTION
•  I- OBTAINING THE PATIENT'S INVITATION
• K- GIVING KNOWLEDGE AND INFORMATION TO THEPATIENT
• E- ADDRESSING THE PATIENT'S EMOTIONS WITH
EMPATHIC RESPONSES
•  S- STRATEGY AND SUMMARY
Preparation
Before Starting …..
• All documents, reports should be studied carefully and
appropriate clinical information should be reviewed in order
to be equipped to handle any questions relating to diagnosis,
treatment or prognosis.

• Mentally rehearse , how to break the news and also all the
possible questions the receiver may ask

• Prepare for emotional outbursts

Preparation (continued …..)

• Arrange for appropriate time and

place without interruptions

• Ask if the receiver wants any other

person to be involved

• Introduce yourself and explain purpose of

the discussion
Avoid …
• Distractions

• Not seeking permission

• Being doubtful

• Being anxious

• own discomfort
What the receiver knows
• After starting …..

Assess
1. Knowledge
• What…. “I know there was a lump”
• How much… “The lump had to be operated”
• Why…. My doctor said…and my son agreed….”

2. Understanding
• Insight into the illness …they could not remove the whole
lump…it is still there
 What the receiver knows
(Continued….)
3. Expectations from the discussion
• “Would you like to know what is happening to you’’

4. Worries
• “ Does that lump bother you”
Warning Shot
• When the patient is ready to take in the
news, it is best to give a warning shot.

• Helps patient to prepare for the news to

come

• May help the health professional to know

if it is time to stop the discussion at this
point of time

• Gives control over the discussion and

they can make way for more information
Giving medical facts
• Talk in the language of the patient

• Go with the patient’s pace and speed

• Explain him the process of events leading to the diagnosis

• Explore his reaction

• Explain the possible treatment options, if or any other plan of

action

Avoid Intellectualization and minimization of facts

Addressing emotions
• Acknowledge emotions

• Help to articulate emotions

• Empathise

• Allow silence or outbursts

• Use of non verbal communication

Planning for the future
• Summarize the discussion

• Ask if any doubts

• Assure availability
whenever needed

• Clarify the do-able and

non- do able options
Take Home Message….
• Appropriate setting
• Permission
• Be clear about messages
• Acknowledge / Validate / Normalize
• Explore current understanding of illness
• Anticipate concerns
• Skilful titration of information
• Listen and watch for cues
• “Check points” – do they understand?
• The Aftermath – follow-up, letting others know, where to go from here